99120038 (2) APOLICANTTO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY O
C3 YOF CUPERTINO BUILDING-ELECTRICAL PERMITNO.
APPLICATION)TERMIT PLUMBING-MECIIANICAI,
BUILDING DIVISION ; BUILDINGPROJECTIDENTWICATION
BUILDING ADDRESSNITARY NO. APPLICATION SUBMIl9'AL DATE
to 334ScEMIC BOuccvKvM 2 -/ 99
VTHI Ct60.61191EL HONE: LIC 25S SO9l uigf �HE�i w ONO 73
NIC CONTROL#
RCHITECI'/ENGINEER: LIC NO: ADURF.SS: ❑
to E.Mnia V& CR 954
CONTACT: PHONE: BUILDING PERMIT INFO
❑ Consultant Fees Paid by Applicant(Initial) BLDG ELECT PL�U-MBT MECH
LICENSED CONTRACTORS DECLARATION QTY ELECTRIC PERMIT FEE
1 notchy affirm m t I- r 1 tensed dap ns or Chapter 9(otnmoet.ag JOB DESCRIPTION
qPZ with Socuon](i D'v' 3ofthe Bo andP fessio:C do and ny hoarser RESIDENTIAL:
WOO in PERMIT ISSUANCE.
F�� full face and effect CA( 374577 _ ❑SFDWL ❑KITCHEN REMODEL
IVU Inonsc Cl u I-io.# APPLIANCIiS-RESIDENTIAL. ❑ADDITION ❑PLUMBING RE-PIPE
Dme , 3 conte. ATF FRT
w d r— ❑MULTI-UNIT El STRUCTURAL
AR(SIII a me DECLARATION O W(y
p,D•/s PANELS MODIFICATION
ZOIR 7J lundersmnd my plans shall Named as public recnNk UP TO 200 AMPS
11 INTERIOR 0 CHIMNEY REPAIR
NaW Lal Licensed Professional 201-IOIXIAMPS IMPROVEMENT (]SWIMMING POOLS
C0 � OWNER-BUILDER DECLARATION OVER I000AMPS ❑BATH REMODF.UREPAIR [I DEMOLITION
C�Q 1 masa afBnn that 1 am exempt from the Contractors siresCur License Law For the
4 U following reason(Section 9031A Business vnd Professions Code:Any city ei county SIGNS ELECTRICAL ®OTHP.R
m B w y wnlmr mqm a vermis ter ra,mmet,rent,improve,dammlah,or territory nmer,re IR.P.�J P td- �•
hat
to the thovisions of fnr Contranninoicere,Law
w( ammcnt SPECIAL CIRCUIT/MISC. -
a y That he is licenkW pumumtlothe provisions of lM1C Commcnr'sl.icemcomm(Chapter9
Lal 0 0 (cam a is owe
ept Seco Iter and of basisnn3 oftheeged wit option,Any vii Code)or TEST.METER OR POLE INST. I F_ COMMERCIAL:
4 c
that he is exempt lherefmli and the basis for the alleged exemption.Any violation of F1 NEW BLDGIAf3DITION ❑DEMOLITION
Section by any applicam fnrapemit subjects the epplicam loacivil penalty of POWER DEVICES ❑TENANT ❑FOODSERVICE
y net more than rive handled dorms(S500). IMPROVEMENT
dO [D1,as owner of the propony,or my employees with wages as their sole compomatioq SWIMMING POOL ELECTRIC
.N. wil]dotire work,and t hesbucnre is not Intended moRered for sale(Sea 7044,Business 11 OTHER
a and Professions Cada:The Contracmr's License Law does net apply to an owner oI OUTLETS-SWITCHES-FIXTURE
properly who builds or improve,theme.,and who docs such work himself m through ^
his own employees,provided Ilet seen improvements arc not intended or offered for NEW RESIDENTIAL FLECTR SQ FI.
sale.If,however,(he buildmgorimprovem tet is sold withinureye r ofamemidema,the / SQ FFIU GORAREA D O.IT.
ownscolaudder will have the burden of parking that he did not build or improve for pur
DEC 6
[:] I ao f the property, d
am exclusively t f g villi I d ron
contractors TOAL: 1999
onnrvdthe in.prel(See 9044 Burnes and Polms,mas Code'.)The CommiLi-
case Law docs not apply to an owner of property who builds or improves thereon,and QTY. PLUMBING PERMITFEE
whe contrails for such projects with a commends)licensed pursuant to Ore ContractorLs
License Law.. PERMIT ISSUANCE t�
❑ 1 am exempt anderSec. .B&P C for this ecaron
.or Dae ALTER-DRAIN&VENT-WATER(EA) VALUATION
WORKER'S COMPENSATION DECLARATION BACK FLAW PROTECT..DEVICE c^
I hamby affirm under penalty of perjury one of Ore following deolamtims: u
❑ I hweund will maintain aCenifiamofConsentn self-immure ForWorker's Comper- DRAINS-FLOOR,ROOF,AREA,COED. STORIES TYPE CONSTRUCTION
kation,am provided for by Section 3700 of the Leber Cede,fnr the pufonnnnce of dm
work an which this permit is issued. FI XTUBES-PER TRAP
I have and will mainmio Workers Compensation Inmrvnse,as required by Section
3700oflhe Labor Code,for the performance from workforwhich this permit is Isomil. GAS-EA.SYSTEM-I INC.4 OUTLETS OCC.GROUP APN
MyWorker TC ren eedonlnsvrnnces nm,T and Policy number are:
Comer: I �Tk �((luy Policy No.:�— CAS-EA.SYSTEM-OVBk4(EA)
CERTIFICATE OF EXEMPTION FROM WO K 5 GREASUINDUSTRI.WASTE INTERCEPTOR COMPENSATION INSURANCE BUILDING DIVISION PEES
(leis section need nm he conrpided l[thc permit is Toon.hundred dollars($100) GREASE'I RAI' a
ter le") PLANCI IECK PEC
I ovary hot inde,perfmnoter of the work far which his permit is issued,i shall SEWER-SAN ITARY-ST ORM EA.20h F1'.
oat employ any person in anymmmt yyyto ,come subject to the Worker,Compete ENERGY FEE
`j. sation Laws of 1J't{jomia.Dlrtl1e �sJ b/.Ga WATER HEATER WNENVELECTR
Z Q Applicant s'TX01r,, 1 �'- GRADING FEE
N NOTICE TO APPLICANT if,after making this Certificate of Exemption,ymt should WATER SYSTEMITREATING
a �^ become subject le the Worker's Compensation provisions tithe Labor Gude,you must SOILS FEE
L1a G farthwi0r comply withsuch provision,or this pennitdoll he doomedrevolast WATER SERVICE
Q
.0.7. z CONSTRUCTION LENDING AGENCY NEW RESIDENTIAL PLMB. SO.FT. PAID Dae Receipt#
Up I for which mvhethemixmommrmlon len ding ugenoy for the performance of
the work for which this Permit Lm issued(Sec 3097,Co.CJ
finder's Name 'TOTAL:
WLender's Address l OTAi. BUILDING FEE
I canny that
1 have rend this city
and c un and sine ems the state information is
,U h manes agree c ur,and with all city and mommy ordbmnoes and nate laws relating to QTY MECHANICAL PERMIT 1 FEE
U � M1uilding constructor,and hereby muthorizereprcsenlativea of this elry to enter upon the SEISMIC PEE
above-mentioned property for inspection purposes. PERMIT ISSUANCE
(We)agree m are Indemnify and keep harmless the City of Cupertino ageinn ELECTRIC FEE
limsIdics,mdgmems,cons andexpenses which new many way acemo agamorloud City ALTER OR ADD'IO MICH.
in consequence of the granting of this permit. PLUMBING FHB
SOURCE REGULATIONS. MECHANICAL.FEE
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT(9'0 10,000 CPM)
AIR HANDLING UNIT(OVER 10,000 CFM) CONSTRUCTION TAX
Signature of Applicant/Contractor tI Date EXHAUST FOOD(W/DUCT') HOUSING MITIGATION FEE
HAZARDOUS MATERIALS DISCLOSURE )'
Widdic applicant or Cam,mildingoceupant store handalloseMous mmcoul HEATING UNIT(TO 100.000 BTU)
as defined by the Carpathian Municipal Coda,Chapter 9.12,and the Health and Safety
Code,Scotian 25532(a)4 Ste. HEATING UNIT(OVER 100,000 BTU)
❑YeY Lgrv'o VENTILATION CAN(SINGLE RESID) PAID
Date Receipt#
Will the air contaminant,
or fore building by the B use equipment or devices which
emit haeallous ah mnmminems as define)by the Bay Arca Air Quality Management BOILER-COMP 0HP OR I00,000 BTU) TOTAL.
Disbitlm. BOILER-COMP(OVER 100,000 BU)
❑Ym NNIr
I have reed the lmzadoms materials Icquirememe ander Chapter 6.95 ollho Cali- AIR CONDITIONER ISSUANCE DATE
foie Health&Safey Code,Sections 25505,25533 and 25534.1 understood that if the NEW RESIDENTIAL MECH. SOLI T.
building does not cumntly have tenant,thus it is my eksponsibila'v to notify the occupant
of the regmirgrm;nls roust i-met priori to trance ora CertiRrnte p[O974ey,
Owner er ulcbmized agent SFW11n'INA'h- �Daatee TOTAL: ISSUED BY.
OFFICE